The following description of the background of the invention is provided as an aid in understanding the invention and is not admitted to describe or constitute prior art to the invention.
ATP-sensitive potassium (KATP) channels play important roles in a variety of tissues by coupling cellular metabolism to electrical activity. The KATP channel has been identified as an octameric complex of two unrelated proteins, which assemble in a 4:4 stoichiometry. The first is a pore forming subunit, Kir6.x, which forms an inwardly rectifying K+ channel; the second is an ABC (ATP binding cassette) transporter, also known as the sulfonylurea receptor (SURx) (Babenko et al., Annu. Rev. Physiol., 60:667-687 (1998)). The Kir6.x pore forming subunit is common for many types of KATP channels, and has two putative transmembrane domains (identified as TM1 and TM2), which are linked by a pore loop (H5). The subunit that comprises the SUR receptor includes multiple membrane-spanning domains and two nucleotide-binding folds.
According to their tissue localization, KATP channels exist in different isoforms or subspecies resulting from the assembly of the SUR and Kir subunits in multiple combinations. The combination of the SUR1 with the Kir6.2 subunits (SUR1/Kir6.2) typically forms the adipocyte and pancreatic β-cell type KATP channels, whereas the SUR2A/Kir6.2 and the SUR2B/Kir6.2 or Kir6.1 combinations typically form the cardiac type and the smooth muscle type KATP channels, respectively (Babenko et al., Annu. Rev. Physiol., 60:667-687 (1998)). There is also evidence that the channel may include Kir2.x subunits. This class of potassium channels are inhibited by intracellular ATP and activated by intracellular nucleoside diphosphates. Such KATP channels link the metabolic status of the cells to the plasma membrane potential and in this way play a key role in regulating cellular activity. In most excitatory cells, KATP channels are closed under normal physiological conditions and open when the tissue is metabolically compromised (e.g. when the (ATP:ADP) ratio falls). This promotes K+ efflux and cell hyperpolarization, thereby preventing voltage-dependent Ca2+ channels (VDCCs) from opening. (Prog. Res Research, (2001) 31:77-80).
Potassium channel openers (PCOs or KCOs; also referred to as channel activators or channel agonists), are a structurally diverse group of compounds with no apparent common pharmacophore linking their ability to antagonize the inhibition of KATP channels by intracellular nucleotides. Diazoxide is a PCO that stimulates KATP channels in pancreatic β-cells (see Trube et al., Pfluegers Arch Eur J Physiol, 407, 493-99 (1986)). Pinacidil and chromakalim are PCOs that activate sarcolemmal potassium channels (see Escande et al., Biochem Biophys Res Commun, 154, 620-625 (1988); Babenko et al., J Biol Chem, 275(2), 717-720 (2000)). Responsiveness to diazoxide has been shown to reside in the 6th through 11th predicted transmembrane domains (TMD6-11) and the first nucleotide-binding fold (NBF1) of the SUR1 subunit.
Diazoxide, which is a nondiuretic benzothiadiazine derivative having the formula 7-chloro-3-methyl-2H-1,2,4-benzothiadiazine 1.1-dioxide (empirical formula C8H7ClN2O2S), is commercialized in three distinct formulations to treat two different disease indications: (1) hypertensive emergencies and (2) hyperinsulinemic hypoglycemic conditions. Hypertensive emergencies are treated with Hyperstat IV, an aqueous formulation of diazoxide for intravenous use, adjusted to pH 11.6 with sodium hydroxide. Hyperstat IV is administered as a bolus dose into a peripheral vein to treat malignant hypertension or sulfonylurea overdose. In these uses, diazoxide acts to open potassium channels in vascular smooth muscle and pancreatic beta-cells, stabilizing the membrane potential at the resting level, resulting in vascular smooth muscle relaxation and suppression of insulin release, respectively.
Hyperinsulinemic hypoglycemic conditions are treated with Proglycem®, an oral pharmaceutical version of diazoxide useful for administration to infants, children and adults. It is available as a chocolate mint flavored oral suspension, which includes 7.25% alcohol, sorbitol, chocolate cream flavor, propylene glycol, magnesium aluminum silicate, carboxymethylcellulose sodium, mint flavor, sodium benzoate, methylparaben, hydrochloric acid to adjust the pH, poloxamer 188, propylparaben and water. Diazoxide is also available as a capsule with 50 or 100 mg of diazoxide including lactose and magnesium stearate. In these uses, diazoxide activated KATP channels in insulin secreting cells thereby blunting the hypersecreting conditions.
Myocardial remodeling late after infarction is associated with increased incidence of fatal arrhythmias. Heterogeneous prolongation of the action potential in the surviving myocardium is one of the predominant causes. Sarcolemmal ATP-dependent potassium (KATP) channels are important metabolic sensors regulating electrical activity of cardiomyocytes and are capable of considerably shortening the action potential. Tavares et al. (Expression and function of ATP-dependent potassium channels in late post-infarction remodeling, J Mol Cell Cardiol 42:1016-1025 (2007)) studied the effect of diazoxide on late post infarction remodeling in rats. Cardiomyocytes were obtained from the infarct border zone, the septum and the right ventricle of rat hearts 10 weeks after coronary occlusion when rats developed signs of heart failure. Expression of the conductance subunit Kir6.1, but not Kir6.2, and of all SUR regulatory subunits was increased up to 3-fold in cardiomyocytes from the infarct border zone. Concomitantly, there was a prominent response of the KATP current to diazoxide that was not detectable in control cardiomyocytes. The action potential was prolonged in cardiomyocytes from the infarct border zone (74 ms) relative to sham (41 ms). However, activation of the KATP channels by diazoxide reduced action potential duration to 42 ms. In myocytes of the septum and right ventricle, expression of channel subunits, duration of action potential, and sensitivity to diazoxide were only slightly increased relative to shams. The authors suggested that drugs selectively activating diazoxide-sensitive sarcolemmal KATP channels should be considered in the prevention of arrhythmias in post-infarction heart failure.
Schwartz et al. (Cardioprotection by multiple preconditioning cycles does not require mitochondrial KATP channels in pigs, Am J Physiol Heart Circ Physiol 283:H1538-H1544 (2002)) studied the effects of diazoxide preconditioning on infarct size in pigs. Diazoxide was administered 3.5 mg/kg, 1 ml/min IV to in barbital-anesthetized open-chest pigs subjected to 30 min of complete occlusion of the left anterior descending coronary artery and 3 h of reflow. Infarct size (percentage of the area at risk) after 30 min of ischemia in controls was 35.1±9.9% (n=7). Diazoxide infusion significantly limited infarct size (14.6±7.4%, n=7). Similar results have been demonstrated in rat and rabbit models.
Diazoxide administered either as an IV bolus or orally has been used to treat pulmonary hypertension. For example, Chan et al. (Reversibility of primary pulmonary hypertension during six years of treatment with oral diazoxide, Br Heart J 57(2):207-209 (1987)) reported the successful treatment of a 32 year old woman with pulmonary hypertension. Her symptoms resolved completely with oral diazoxide and the pulmonary arterial pressure was reduced to normal levels over a period of six years. When diazoxide was discontinued on two separate occasions pulmonary hypertension recurred. Squarcia et al. (Primary pulmonary hypertension in childhood: familial aspects, Pediatr Med Chir 3(6):467-472 (1981)) suggested that among alternative vasodilators available for the experimental treatment of pulmonary hypertension diazoxide appears to have some advantages because it reduces not only pulmonary arteriolar resistance, but also pulmonary artery pressure, without producing tachycardia.
Honey et al. (Clinical and hemodynamic effects of diazoxide in primary pulmonary hypertension, Thorax 35(4):269-276 (1980)) studied the effects of IV and oral diazoxide on primary pulmonary hypertension. In their study diazoxide was injected into the pulmonary artery in nine patients with primary pulmonary hypertension. There was no significant change in pulmonary artery pressure, which fell by more than 10 mmHg in only two patients. The pulmonary blood flow increased in all patients as a result of a fall in pulmonary vascular resistance (by 4 to 17 units). Systematic vascular resistance also fell as expected in all patients. Oral diazoxide was given to seven patients, two of whom showed sustained clinical improvement while remaining on treatment (400 to 600 mg daily). Five patients were unable to tolerate the drug, because of nausea and sickness (two), peripheral edema requiring large doses of diuretics (four), diabetes (three), and postural hypotension (one). Hirsutism was troublesome in the two patients remaining on treatment. They concluded that diazoxide may be useful in the management of some patients with primary pulmonary hypertension, but its use is limited by the frequency of side effects.
Several experimental formulations of diazoxide have been tested in humans and animals. These include an oral solution tested in pharmacodynamic and pharmacokinetic studies and a tablet formulation under development in the early 1960's as an anti-hypertensive, but never commercialized (see Calesnick et al., J. Pharm. Sci. 54:1277-1280 (1965); Reddy et al., AAPS Pharm Sci Tech 4(4):1-98, 9 (2003); U.S. Pat. No. 6,361,795).
Current oral formulations of diazoxide are labeled for dosing two or three times per day at 8 or 12 hour intervals. Most subjects receiving diazoxide are dosed three times per day. Commercial and experimental formulations of diazoxide are characterized by rapid drug release following ingestion with complete release in approximately 2 hours. Unless indicated differently, the term “approximately” when used in the context of a numeric value, refer to the stated numeric value +/−10%. In the context of two-theta angles from XRPD studies, the term approximately refers to +/−5% of the stated numeric value.
Current oral formulations of diazoxide in therapeutic use result in a range of adverse side effects including dyspepsia, nausea, diarrhea, fluid retention, edema, reduced rates of excretion of sodium, chloride, and uric acid, hyperglycemia, vomiting, abdominal pain, ileus, tachycardia, palpitations, and headache. (See e.g., current packaging insert for Proglycem®). Oral treatment with diazoxide is used in individuals experiencing serious disease where failure to treat results in significant morbidity and mortality. The adverse side effects from oral administration are tolerated because the benefits of treatment are substantial. The adverse side effects profile of oral diazoxide limit the utility of the drug in treating obese subjects at doses within the labeled range of 3 to 8 mg/kg per day.
The effect of diazoxide in animal models of diabetes and obesity (e.g. obese and lean Zucker rats) has been previously reported. See e.g. Alemzadeh et al., Endocrinology 133:705-712 (1993); Alemzadeh et al., Metabolism 45:334-341 (1996); Alemzadeh et al., Endocrinology 140:3197-3202 (1999); Stanridge et al., FASEB J 14:455-460 (2000); Alemzadeh et al., Med Sci Monit 10(3): BR53-60 (2004); Alemzadeh et al., Endocrinology 145(12):3476-3484 (2004); Aizawa et al., J of Pharma Exp Ther 275(1): 194-199 (1995); and Surwit et al., Endocrinology 141:3630-3637 (2000).
The effect of diazoxide in humans with obesity or diabetes has been previously reported. See e.g., Wigand et al., Diabetes 28(4):287-291 (1979), evaluation of diazoxide on insulin receptors; Ratzmann et al., Int J Obesity 7(5):453-458 (1983), glucose tolerance and insulin sensitivity in moderately obese patients; Marugo et al., Boll Spec It Biol Sper 53:1860-1866 (1977), moderate dose diazoxide treatment on weight loss in obese patients; Alemzadeh et al., J Clin Endocr Metab 83:1911-1915 (1998), low dose diazoxide treatment on weight loss in obese hyperinsulinemic patients; Guldstrand et al., Diabetes and Metabolism 28:448-456 (2002), diazoxide in obese type II diabetic patients; Ortqvist et al., Diabetes Care 27(9):2191-2197 (2004), beta-cell function measured by circulating C-peptide in children at clinical onset of type 1 diabetes; Bjork et al., Diabetes Care 21(3):427-430 (1998), effect of diazoxide on residual insulin secretion in adult type I diabetes patients; and Qvigstad et al., Diabetic Medicine 21:73-76 (2004).
The effect of potassium channel openers on lipid levels has been reported. Gutman et al. (Horm Metab Res 1985 17(10):491-494) studied the effect of diazoxide on an animal model with elevated triglycerides. Normal Wistar rats fed an isocaloric, sucrose-rich (63%) diet (SRD), were reported to develop glucose intolerance and elevated triglyceride levels in plasma (P) as well as in heart (H) and liver (L) tissue. This metabolic state was reported to be accompanied by hyperinsulinism both in vivo and in vitro, consistent with a state of insulin resistance. Gutman et al., administered diazoxide (120 mg/kg/day) together with the diet (SRD+DZX) for 22 days. Control groups fed a standard chow (STD) or the STD plus diazoxide (STD+DZX) were included in the study. Gutman et al., suggested that diazoxide could prevent the development of hyperinsulinism, glucose intolerance and elevated levels of triacylglycerol in plasma, heart and liver present in animals fed on a sucrose rich diet.
Yokoyama et al. (Gen Pharmacol 1998 30(2):233-237) studied the effects of KRN4884 on lipid metabolism in hyperlipidemic rats. KRN4884 is a novel pyridinecarboxamidine type potassium channel opener. Oral administration of KRN4884 (1-10 mg/kg/day) for 14 days was reported to dose dependently reduce serum triglyceride levels in Zucker rats. The reductions in serum triglyceride were associated with reductions in triglyceride in chylomicron and very low density lipoprotein. KRN4884 produced no change in serum insulin and glucose levels in Zucker rats. KRN4884 exhibited a similar triglyceride lowering effect in diet-induced hyperlipidemic rats. In a second study with KRN4884 (J Cardiovasc Pharmacol 2000 35(2):287-293), these authors used high-fructose diet rats which developed hypertension, hypertriglyceridemia, increased total cholesterol/HDL (high-density lipoprotein)-cholesterol ratio, and hyperinsulinemia, and reported that KRN4884 treatment significantly increased lipoprotein lipase (LPL) activity in muscle and tended to increase LPL activity in adipose tissue. Hepatic triglyceride lipase activity was not affected by KRN4884 administration.
Matzno et al. (J Pharmacol Exp Ther 1994 271(3):1666-71) studied the effect of (+)-N-(6-amino-3-pyridil)-N′-[(1S,2R,4R)-bicyclo-[2.2.1]hept-2-yl]-N″-cyanoguanidine hydrochloride (AL0671), a cyanoguanidine-derivative potassium channel opener, on serum lipid and lipoprotein levels in obese Zucker rats. Serial administration (for 1 or 2 weeks) of AL0671 (5 mg/kg/day) was reported to significantly decrease serum total triglyceride, chylomicron and very-low-density lipoprotein levels with increasing high-density lipoprotein cholesterol, whereas low-density lipoprotein levels did not change. AL0671 (5 mg/kg/day) also was reported to increase lipoprotein lipase activities 4-fold and hepatic triglyceride lipase activities 3-fold in postheparin plasma. The authors suggested that AL0671 activates both lipoprotein lipase and hepatic triglyceride lipase activities through its potassium channel-opening activity followed by decreasing triglyceride-rich lipoproteins in genetically obese hyperlipemic rats.
Alemzadeh and Tushaus (Med Sci Monit, 2005; 11(12): BR439-448) studied the effect of 8 weeks of diazoxide treatment (150 mg/kg/day) on triglyceride biosynthesis in Zucker Diabetic Fatty (ZDF) rats. They reported that diazoxide treatment significantly reduced expression of sterol regulatory element-binding protein-1c, fatty acid synthase, acetyl CoA carboxylase, hormone-sensitive lipase, and peroxisome proliferator agonist receptor-γ, without altering expressions of acyl CoA oxidase, peroxisome proliferator receptor-α, and carnitine palmitoyl transferase-1. Also reported was that diazoxide treatment decreased hepatic triglycerides, long chain acyl-CoA and cholesterol contents.
U.S. Pat. No. 5,284,845 describes a method for normalizing blood glucose and insulin levels in an individual exhibiting normal fasting blood glucose and insulin levels and exhibiting in an oral glucose tolerance test, elevated glucose levels and at least one insulin level abnormality selected from the group consisting of a delayed insulin peak, an exaggerated insulin peak and a secondary elevated insulin peak. According to this reference, the method includes administering diazoxide in an amount from about 0.4 to about 0.8 mg/kg body weight before each meal in an amount effective to normalize the blood glucose and insulin levels.
U.S. Pat. No. 6,197,765 describes administration of diazoxide for treatment for syndrome-X, and resulting complications, that include hyperlipidemia, hypertension, central obesity, hyperinsulinemia and impaired glucose tolerance. According to this reference, diazoxide interferes with pancreatic islet function by ablating endogenous insulin secretion resulting in a state of insulin deficiency and high blood glucose levels equivalent to that of diabetic patients that depend on exogenous insulin administration for normalization of their blood glucose levels.
U.S. Pat. No. 2,986,573 describes the preparation of diazoxide and its use for the treatment of hypertension. The patent asserts that alkali metal salts may be prepared by methods well-known in the art for the preparation of a salt of a strong base with a weak acid. It also alleges a specific method for making a sodium salt of diazoxide. This patent does not provide any evidence to support the formation of any salt of diazoxide.
U.S. Pat. No. 5,629,045 describes diazoxide for topical ophthalmic administration.
WO 98/10786 describes use of diazoxide in the treatment of X-syndrome including obesity associated therewith.
U.S. Patent publication no. 2003/0035106 describes diazoxide containing compounds for reducing the consumption of fat-containing foods.
U.S. Patent Publication No. 2004/0204472 describes the use of a Cox-2 inhibitor plus diazoxide in the treatment of obesity. Also described therein is the use of a Cox-2 inhibitor plus a pharmaceutically acceptable salt of diazoxide, wherein acceptable cations include alkali metals and alkaline earth metals.
U.S. Patent Publication No. 2002/0035106 describes use of KATP channel agonists for reducing the consumption of fat containing food. This application mentions pharmaceutically acceptable acid addition salts, pharmaceutically acceptable metal salts and optionally alkylated ammonium salts, but does not disclose or describe how to prepare any such salts. This patent also does not provide any evidence to support the formation of any salt of a KATP channel agonist.
U.K. Patent GB982072 describes the preparation and use of diazoxide and derivatives for the treatment of hypertension and peripheral vascular disorders. This patent mentions non-toxic alkali metals salts but does not disclose or describe how to prepare any such salts. This patent does not provide any evidence to support the formation of any salt of diazoxide or its derivatives.